1. Health Scientist (Informatics)
N E A R S National Environmental Assessment Reporting System formerly known as National Voluntary Environmental Assessment Information System (NVEAIS)
Erik W. Coleman, MPH
Health Scientist (Informatics)
We hope this presentation will encourage you to improve your competency on conducting environmental assessments as part of foodborne outbreaks and report those data to CDC.
National Center for Environmental Health
Division of Emergency and Environmental Health Services

2. Chipotle Mexican Grill plans to start reopening 14 restaurants in Oregon and 29 in Washington which it closed down Oct. 31 following an E. coli outbreak.
Company spokesman Chris Arnold said that the 43 shuttered outlets will begin doing business again on Wednesday, Nov. 11.
At least 49 people (3o in WA and 19 in OR) were sickened and 14 were hospitalized in the outbreak, and 11 of the company’s “fast casual” restaurants in OR and WA were the common denominator among some of those who became ill. No deaths or cases of hemolytic uremic syndrome (HUS), a dangerous complication from E. coli infection, have been reported.
“Is there any place that compiles a list of repeat offenders? I mean, I feel like I hear Chipotle an awful lot in these sorts of things.”
“No you are right this would be the third outbreak associated with Chipotle that I have heard of this year. I'm wondering if its bad food safety practices in house that is causing this or can it be traced back to a food supplier? Either way something needs to change...”

3. Driving to Improve Food Safety Are We There Yet?
National Environmental Assessment Reporting System (NEARS)
Food – Next Exit
NORS
PulseNet
Achieving food safety success may be closer than you think. It is ‘NEARS’.
After much consideration and thought we have decided to change the name of the National Voluntary Environmental Assessment Information System (NVEAIS) to the National Environmental Assessment Reporting System (NEARS)
New name…
1. Doesn’t include the term ‘voluntary’
2. Is shorter/less awkward
3. Compliments the National Outbreak Reporting System (NORS)
CaliciNet

4. Food Safety Goal and Priorities
Centers for Disease Control and Prevention
National Center for Environmental Health
Division of Emergency and Environmental Health Services
Goal
Improve environmental public health practice to prevent foodborne outbreaks
Priorities
Improve reporting of environmental factors that contribute to foodborne outbreaks
Strengthen federal, state, local, and industry policies and practices
Foodborne illness and outbreaks pose a significant public health problem in the U.S.
Division Food Safety Goal
Ensure safe food at U.S. restaurants and other food service establishments by improving environmental public health practice to prevent foodborne outbreaks
Division Food Safety Priorities
Improve reporting of environmental factors that contribute to foodborne outbreaks
NEARS
Environmental Assessment Training
2. Strengthen federal, state, local, and industry policies and practices in 3 areas
Hand hygiene
Ill workers
Kitchen manager certification

5. Environmental Factor Data Assists to Prevent Foodborne Outbreaks
The Road Less Traveled
Environmental Health Specialists Network
(EHS-Net)
Surveillance
Practice-based Research
Evidence-based Practice
The ultimate goal for public health and food safety officials is not just stopping foodborne disease outbreaks once they occur, but preventing them from happening in the first place.
Despite the fact that thousands of employees have been trained in food safety around the world, millions have been spent globally on food safety research, and countless inspections and tests have been performed, food safety remains a significant public health challenge. Why is that?
Food safety is an ever changing environment that may require us to go beyond traditional trainings and routine inspections. As food safety officials we have a responsibility to drive/guide improved food safety policies and practices.
Within NCEH/EEHS’ Environmental Health Specialists Network (EHS-Net) we work to improve environmental health practice by identifying and preventing environmental factors contributing to foodborne outbreaks.
ROAD WORK
AHEAD

6. Outbreak Investigations
Public health officials investigate outbreaks to control them, prevent additional illnesses, and to learn how to prevent similar outbreaks from happening in the future.
Outbreak Investigations

7. Foodborne Outbreak Investigation Components
Epidemiological
Determine the who, what, when, where of an outbreak
Laboratory
Identify or confirm the agent causing the outbreak
Environmental
Assess how and why the agent got into the environment and spread
Recommend steps to stop outbreaks and prevent future ones
Outbreak investigations typically involve epidemiology, laboratory, and environmental health (EH) staff—the three legs of the stool—as well as partners in risk communication, public health, industry, and other disciplines.
Outbreak investigations are also opportunities for different authorities and professionals to work together as a team.  They may reveal points at which the public health systems that detect and respond to outbreaks can be improved.
Outbreak investigations and additional research should result in better industry practices, better regulations and enforcement by the regulatory agencies, and better consumer understanding, all of which should reduce the number of foodborne illnesses that occur.

8. The Environmental Component of a Foodborne Outbreak Investigation
Environmental Health Specialists
Continuously focus on
People
Process
Equipment
Economics
Food
Identify how and why an outbreak occurs
Assist in the development of effective interventions to prevent future foodborne outbreaks
For the purpose of this presentation we will focus on the environmental component of a foodborne outbreak investigation.

9. Environmental Assessment as part of a Foodborne Outbreak Investigation
Describes how the environment contributes to the introduction and/or transmission of agents that cause illness
Objectives of an environmental assessment
Identify contributing factors
Identify environmental antecedents
Generate recommendations for informed interventions
Environmental assessment is at the heart of much of what food regulatory programs do on a day to day basis.
Typically conducted by an environmental health specialist, a foodborne outbreak environmental assessment is very different from the other types of environmental assessments food programs conduct on a daily basis. The challenge of a foodborne outbreak Environmental Assessment is the reconstruction of past events.
Even more challenging is the fact that these assessments represent one component of a response that involves not only the food program but often, epidemiologists, laboratory professionals and possibly others from other program areas, who are working as a team to help reconstruct past events.
The objectives of the assessment include
Identifying contributing factors
Identifying environmental antecedents
Generating recommendations for informed interventions

10. Environmental Assessment as part of a Foodborne Outbreak Investigation
Contributing Factors
Factors that caused the outbreak
How the outbreak occurred
Environmental Antecedents
Factors that led to the contributing factors
Why the outbreak occurred
Contributing factors are determinants that directly or indirectly cause an outbreak. They describe how the outbreak occurred. They are categorized as Contamination Factors, Proliferation Factors and Survival Factors. Contributing factors are specific to an outbreak event, and may or may not reflect code or regulation violations. For example, contributing factors related to a viral outbreak may include workers working while ill or poor personal hygiene but evidence of improper cold holding, while it might be a code violation, it would not be reported as a contributing factor in an outbreak.
Environmental Antecedents are factors that led to the contributing factors and describe why the outbreak occurred. Based on our work with EHS-Net we have identified categories of potential antecedents. They include people, equipment, process, food, and economic factors. Of course these categories are not set in stone and we expect that as we get more experience using these categories there may be others that should be considered.

11. Environmental Assessment as part of a Foodborne Outbreak Investigation
Norovirus
Outbreak caused by sandwiches eaten at a restaurant
Contributing Factors
Worker did not properly wash hands after using restroom
Worker prepared sandwiches using bare hands
Worker worked while ill
Environmental Antecedents
Hand sinks did not have soap
Restaurant did not have disposable gloves
No paid sick leave

12. Conducting an Environmental Assessment as part of a Foodborne Outbreak Investigation
Step 1
Planning and Preparation
Step 2
Site Visit
Step 3
Assess Information and Identify Contributing Factors
Step 4
Make Recommendations for Control Strategies
Step 5
Reporting
Conducting environmental assessments.
The first major stage is Planning and Preparation. You should actually plan and prepare for a foodborne outbreak investigation before an outbreak is identified.  
Once an outbreak is identified, the planning and preparation stage is where you come up to speed with the investigation and coordinate your role with others involved in the investigation. This stage typically includes all members of the outbreak investigation team, including environmental health, epidemiology, and laboratory, as well as local, state, federal, tribal, or territorial officials, as appropriate.
During the Site Visit you'll conduct interviews, perform a walkthrough and observations, collect samples for tests you and the laboratory have agreed upon, and review establishment records. 
The next stage of a foodborne outbreak environmental assessment is assessing the information you've gathered thus far to identify the outbreak's contributing factors and environmental antecedents.
The next stage of a foodborne outbreak environmental assessment is where you make recommendations for control strategies.
Some control strategies reflect steps that should be taken immediately to stop the outbreak and prevent the further spread of this agent.  Longer term strategies are important for reducing the likelihood of any future outbreaks at this type of establishment.  
We've now come to the last stage in the foodborne outbreak environmental assessment: reporting the findings and outcomes.  In this stage you'll prepare a report summarizing the findings of the environmental assessment, including the likely variables involved in this outbreak and their negative influences. The report might also include such things as food flow diagrams, summaries of interviews and observations, identification of contributing factors and environmental antecedents, and recommended control strategies.  The report should comment on the effectiveness of the recommended strategies in influencing the establishment's the food safety set point.
This report will become part of the foodborne outbreak investigation report. That report will include all aspects of the investigation, including epidemiological and laboratory information.  These data should be reported to the National Environmental Assessment Reporting System (NEARS).

13. Why Improve Reporting of Environmental Assessment Data that Contribute to Foodborne Outbreaks
Environmental assessment data are key to…
Understand how and why outbreaks occur
Develop appropriate guidelines, policies and practices
Prevent future outbreaks
Limited information on environmental assessment data have been reported to CDC
Engagement of environmental (regulatory) officials responsible for the environmental investigation
Link to National Outbreak Reporting System (NORS)
We can not overstate the value of reporting environmental assessment data.

14. Sites Reporting Environmental Assessment Data to NEARS
Change agents!
Currently, there were 19 jurisdictions registered to begin reporting data into the system. This includes 13 states, and 6 local health departments.
State Agencies
Alaska Department of Environmental Conservation
California Department of Health
Connecticut Department of Health
Iowa Department of Health
Michigan Department of Agriculture and Rural Development
Minnesota Department of Health
New York State Department of Health
North Carolina Department of Health and Human Services
Oregon Health Authority
Rhode Island Department of Health
South Carolina Department of Health and Environmental Control
Tennessee Department of Health
Wisconsin Department of Health
Local Agencies
Davis County (UT) Health Department
Fairfax County (VA) Health Department
Harris County (TX) Health Department
Kansas City (MO) Health Department
New York City of Health and Mental Hygiene
Southern Nevada Health District
We need all food safety programs to register and report their foodborne outbreak environmental assessments to collect enough data for CDC to provide food safety programs and industry the information they need to better understand and prevent the environmental causes of foodborne outbreaks.
NEARS
STATE
LOCAL

15. Surveillance

16. National Outbreak Reporting System (NORS)
Information gaps ?
Currently, the National Outbreak Reporting System (NORS) is foodborne outbreak surveillance system that all states report to, contributing factors (what happened to cause an outbreak environmentally) are not reported very often and is sometimes inaccurate when reported.
No information is reported regarding environmental antecedents (why contributing factors occurred).
Information regarding both contributing factors and environmental antecedents are pivotal to the development of policies and/or practices to keep food safe or to understand why policies and/or practices designed to keep foods safe are not properly implemented.
Understanding how and why outbreaks occur is at the heart of preventing them in the future.
Collects outbreak data on date and location of the outbreak, the number of people who became ill and their symptoms, and the pathogen that caused the outbreak.

17. National Environmental Assessment Reporting System (NEARS)
Information gaps NEARS data fills !
NEARS is a companion surveillance system to NORS which captures environmental assessment data.
The National Voluntary Environmental Assessment Information System (NEARS) is a surveillance system targeted to jurisdictions that inspect and regulate restaurants and other food venues such as banquet facilities, schools, and other retail food service locations. The system provides an avenue to capture environmental assessment data that describes foodborne outbreaks associated with restaurants and other retail food service venues.
These data will help identify factors that food safety programs can routinely monitor to prevent or reduce the risk for foodborne outbreaks associated with food service establishments.
Collects outbreak data on contributing factors and their environmental antecedents.

18. NEARS Data Reporting Instrument
Part 1
General Characterization of Outbreak
Part 2
Establishment Description
Part 3
Manager Interview
Part 4
Establishment Observation
Part 5
Suspected/Confirmed Food
Part 6
Sampling
Part 7
Contributing Factors
To take this down from the 50,000 foot level let me describe the NEARS data collection instrument.
Part I provides the epidemiological context for the outbreak.
Part II gathers basic information about the sanitation infrastructure of the establishment.
Part III characterizes the policies and practices in this establishment based on a structured manager interview.
Part IV collects information concerning the establishment based on observation of the facility and practices used during the environmental assessment.
Part V is a systematic review of the food preparation process of the suspected/confirmed food.
Part VI provides information on any environmental or food sampling.
Part VII describes contributing factors that introduce or otherwise permit contamination, proliferation/amplification, and survival of pathogens.

19. The Flow of Outbreak Data
Health department is notified of possible outbreak
MILE 3
SPEED
LIMIT 25
People get sick and may or may not seek treatment
MILE 2
People are exposed to a hazard
MILE 1

20. The Flow of Outbreak Data
CDC reviews environmental assessment data for accuracy and analysis
MILE 6
Health department enters environmental assessment data into NEARS
SPEED
LIMIT 25
MILE 5
Health department conducts an environmental assessment as part of outbreak investigation
MILE 4

21. Immediate Outcomes for Reporting Outbreak Data to NEARS
Increase reporting of environmental assessment data
Access to practical information about conducting environmental assessments
Helps improve participants’ outbreak investigation ability and expertise
Access to a free data entry and storage system
NEARS data is immediately accessible after entry
It is important to remember that NEARS is a surveillance system. By their nature, surveillance systems are not designed to provide immediate benefits to participants (unless they are being paid to participate!)-- they are designed to provide benefits over the long term. But, here are some thoughts on more immediate benefits:
Increase the reporting of environmental assessment data.
The NEARS manual and data reporting instrument, and its accompanying outbreak environmental assessment training, provides participants with useful, practical information about conducting environmental assessments during foodborne illness outbreaks.
NEARS provides an easy, free, and intuitive data entry and storage system. Each site’s data entered into NEARS are immediately accessible to them.

22. Improve Foodborne Outbreak Response
NEARS Data
Improve Foodborne Outbreak Response
Identify program factors that lead to contributing factors and confirmed (vs. suspected) foodborne outbreaks
Outbreak response timeliness
Quality of communication
Specific investigation activities (manager interviews, sampling, epi investigation)
Questions NEARS data may be able to answer.

23. Improve Retail Food Safety
NEARS Data
Improve Retail Food Safety
Identify contributing factors associated with specific foodborne outbreaks
More complete data on contributing factors
Identify environmental antecedents associated with foodborne outbreaks
Bacterial outbreaks
Lack of consumer advisories and temperature policies
Viral outbreaks
Lack of ill worker policies
Customer access to food
Questions NEARS data may be able to answer.

24. 2014 NEARS Data 111 outbreaks reported
(CA, CT MN, NY, NYS, RI, TN, WI)
Norovirus (47%) most commonly reported identified primary agent
Restaurants (87%) most commonly reported facility type
Contributing factors identified in 58% of outbreaks
C10 (22%), C12 (17%), C11 (6%)
Preliminary data.
Norovirus 47% (52 of 111)
Salmonella 14% (15 of 111)
Toxic agent 3% (3 of 111)
Restaurant 87% (97 of 111)
Caterer 5% (6 of 111)
Contributing factors identified in 58% (63 of 108)
C10 – 22% (21 of 95)
C12 – 17% (16 of 95)
C % (6 of 95)
C10 Bare-hand contact by a food handler/worker/preparer who is suspected to be infectious (e.g., with ready-to-eat-food): A food worker suspected to be infectious uses his or her bare hands to touch or prepare foods that are not subsequently cooked. The term “infectious” is an all-inclusive term used to describe all persons who are colonized by, infected with, a carrier of, or ill due to a pathogen. This is a typical situation that precedes outbreaks caused by norovirus or staphylococcal enterotoxins.
C11 Glove-hand contact by a food handler/worker/preparer who is suspected to be infectious (e.g., with ready-to-eat-food): A food worker suspected to be infectious uses his or her gloved hands to touch or prepare foods that are not subsequently cooked. The term “infectious” is an all-inclusive term used to describe all persons who are colonized by, infected with, a carrier of, or ill due to a pathogen. This is a typical situation that precedes outbreaks caused by norovirus or staphylococcal enterotoxins.
C12 Other mode of contamination (excluding cross-contamination) by a food handler/worker/preparer who is suspected to be infectious: A food worker suspected to be infectious contaminates the food by another mode of contamination other than bare-hand contact or glove-hand contact, or an epidemiological/environmental investigation determines that an infectious food worker contaminates food with his or her hands but the investigation is unable to determine whether or not the food worker was wearing gloves during food preparation. This contaminated food is subsequently not cooked.

25. 2014 NEARS Data
Preliminary data.

26. 2014 NEARS Data
Preliminary data.

27. Linking Foodborne Outbreak Data at CDC
NORS
Initial Exposure Date: 3/7/2014
Date First Ill: 3/8/2014
Facility: Restaurant (sit-down dining)
Agent: Norovirus (Genogroup II)
Estimated total primary cases: 12
Symptoms: Abdominal cramps, vomiting, diarrhea
Number laboratory confirmed: 4
Implicated Food: Cranberry coleslaw (cabbage)
Epidemiological evidence to implicate food worker.
NEARS
Date establishment was identified for an EA: 3/10/2014
Date of first contact with establishment mgmt: 3/10/2014
Establishment Type: Restaurant (complex), American (menu type), Saturday busiest day of the week, 800 meals served daily
Contributing Factor(s): C12-Other mode of contamination (excluding cross-contamination) by a food handler/worker/preparer who is suspected to be infectious.
Establishment Observation: Hands sink properly equipped, adequate glove supply, no bare hand contact w/ RTE foods
Health Polices: Written ill worker policy, written policy or procedure to restrict or exclude ill workers
Managers receive paid sick leave. Food workers were not noted as receiving paid sick leave.
***Animation***
87% of outbreaks reported to NEARS were reported to NORS
NORS and NEARS Workgroup formed in May 2014 by CDC staff to:
Improve reporting of foodborne outbreak data from state and local health departments to CDC (NEARS and NORS).
Reduce the burden of reporting overlapping/complimentary foodborne outbreak data to CDC (NEARS and NORS).
MN Norovirus Outbreak—Cranberry coleslaw
NORS #18042
2/3 female
1/3 male
Age: Most y/o
NEARS #5982
1 visit to complete the EA.

28. NEARS Participation

29. Benefits of Reporting Environmental Assessment Data to NEARS
Environmental Health Programs
Annual report from CDC summarizing your NEARS data
Collaboration/communication with other states/localities participating in NEARS
Scientific publication opportunities
Document and track foodborne outbreak response data
Meet FDA Retail Food Regulatory Program Standards
Standard 5 recommendations
Voluntary National Retail Food Regulatory Program Standards
STANDARD 5
FOODBORNE ILLNESS AND FOOD DEFENSE PREPAREDNESS AND RESPONSE
This standard applies to the surveillance, investigation, response, and subsequent review of alleged food-related incidents and emergencies, either unintentional or deliberate, which results in illness, injury and outbreaks.

30. Anticipated Benefits of Reporting Environmental Assessment Data to NEARS
Epidemiology, Laboratory, and Environmental Health Programs
Robust national description of outbreak data
Prevention of cases and deaths
Fewer social and economic disruptions (including disruptions to food production and manufacturing) when epidemics are prevented
Cost savings
Social and psychological benefits stemming from less apprehension when outbreaks are rare or non-existent
Source:

31. Visit the following website for more information:
How to Begin Reporting Your Program’s Foodborne Outbreak Environmental Assessment Data to NEARS
Commit to conducting foodborne outbreak environmental assessments
Complete NEARS Registration Forms
State Notice and Acknowledgment of Local Participation
Notice of Participation Form
Complete CDC’s free online environmental assessment training
Visit the following website for more information:

32. Environmental Assessments
Only YOU Can Prevent
Foodborne Outbreaks
Conduct More
Environmental Assessments
OPPORTUNITY
AHEAD
In closing, having a robust national description of the environmental factors of foodborne outbreaks for the establishments that represent 68% of the foodborne outbreaks reported in this country can make the difference between driving in circles (doing the same things over and over) expecting progress and having information to develop new policies and practices and being able to evaluate them.
Be a change agents in your respective jurisdictions to prevent foodborne outbreaks. If not you, then who?
KEEP
RIGHT
NEARS

33. Thank You! National Center for Environmental Health
Environmental Health Services Branch